2008 ILLINOIS STATE UNIVERSITY MOTORCYCLE SAFETY COURSE REGISTRATION FORM

 

All requested information must be completed.  Incomplete forms will be returned.  Use separate forms for each applicant.  This form may be photocopied. Complete this form and mail it, with your course registration fee to:

ILLINOIS STATE UNIVERSITY

5221 MOTORCYCLE SAFETY

411 W. Willow

NORMAL, IL  61790-5221

 

Check one:  Mr. ___   Mrs. ___   MS ___   Miss ___                                                                        Age _______

 

PLEASE PRINT CLEARLY

 

NOTE:  Name must appear as it does on your driver’s license.  

 

Last Name:  ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___  

                                    

First Name: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___   MI:  ___

 

Address:  _________________________________________________________________________

 

City:  ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___   State: ______   Zip Code: _____________

 

Day Phone #: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___    Evening Phone #: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

 

e-mail:  _____________________________________________________

 

 

Date of Birth: ___ ___ - ___ ___ - ___ ___          Sex:   Male _____  Female _____

                        M    M      D    D       Y   Y             

 

Valid Driver License #:___ ___ ___ ___-___ ___ ___ ___-___ ___ ___ ___ State: ____ ____

  

Driver License Classification(s) – circle all that are current:    A     B     C     D      L     M      CDL

 

I certify that the above information is complete, accurate, and correct.  I have read and understand the registration, transfer, cancellation, and fee refund policy of the Illinois State University Motorcycle Safety Program.

 

Signature:  ________________________________________________       Date:     ___ ___ - ___ ___ - ___ ___      

 

CHECK COURSE TYPE:    ______ Basic   or   ______ ERC           List courses requested in priority order:                                  

 

First Choice                      Course #: __________________                Course Dates: _______________________  

 

Second Choice                 Course #: __________________                 Course Dates: _______________________  

 

Third Choice                     Course #: __________________                Course Dates: _______________________  

 

Fourth Choice                 Course #: __________________                 Course Dates: _______________________  

 

Fifth Choice                      Course #: __________________                Course Dates: _______________________  

 

Sixth Choice                      Course #: __________________                Course Dates: _______________________  

 

CHECK ONE (required):  If all your choices are full, which of the following would you prefer?

 

________ Next available class            ________ Waiting List            ________ Do not register, return fee

 

Registration Fee enclosed:  $ 20.00 per person, payable to ISU Motorcycle Safety (no credit or debit cards accepted)

 

Check # __________                      Money Order # __________